Understanding how socioeconomic inequalities drive inequalities in COVID-19 infections.

Across the world, the COVID-19 pandemic has disproportionately affected economically disadvantaged groups. This differential impact has numerous possible explanations, each with significantly different policy implications. We examine, for the first time in a low- or middle-income country, which mechanisms best explain the disproportionate impact of the virus on the poor. Combining an epidemiological model with rich data from Bogotá, Colombia, we show that total infections and inequalities in infections are largely driven by inequalities in the ability to work remotely and in within-home secondary attack rates. Inequalities in isolation behavior are less important but non-negligible, while access to testing and contract-tracing plays practically no role because it is too slow to contain the virus. Interventions that mitigate transmission are often more effective when targeted on socioeconomically disadvantaged groups.

Emergency surgery workforce and its inverse relationship with multidimensional poverty in Colombia.

PURPOSE: General surgeons, anesthesiologists, obstetricians and gynecologists (ob-gyns), and orthopedic surgeons are the vital disciplines to provide emergency surgery within a healthcare system. This paper aims to examine the relationship (if any) between multidimensional poverty (MDP) and GDP per-capita with the emergency surgery workforce density in Colombia. METHODS: We performed an ecological study, where the observation units were the 32 Colombian departments. The total numbers of general surgeons, anesthesiologists, ob-gyns, and orthopedic surgeons were obtained from the "Registro Unico Nacional de Talento Humano en Salud" (ReTHUS) registry. The 2020 population projections, the incidence of MDP and the GDP per capita were obtained from the Colombian National Administrative Department of Statistics. A spearman's correlation coefficient was calculated to measure the strength of the correlations between the surgical workforce density with MDP and GDP per-capita. RESULTS: There were significant moderate inverse linear correlations between the incidence of multidimensional poverty and workforce density. The correlation coefficients for the incidence of multidimensional poverty and the workforce density were - 0.5273, - 0.5620, - 0.4704, and - 0.4612 for surgeons, anesthesiologists, ob-gyns, and orthopedic surgeons, respectively. Conversely, the correlation coefficients for the GDP per-capita and the workforce density were 0.4045, 0.3822, 0.4404, and 0.3742 for surgeons, anesthesiologists, ob-gyns, and orthopedic surgeons, respectively. CONCLUSION: This study found that Colombian trauma and emergency surgery workforce density was inversely and directly correlated with multidimensional poverty and GDP per-capita levels, respectively. The relationship of these economic indicators with the surgical capacity deserves further investigation.

Mortality from anti-personnel mines before and during the Colombian peace process / Mortalidad secundaria a minas antipersona antes y durante el proceso de paz colombiano

Abstract Introduction: Although the peace process in Colombia resulted in a significant reduction in the number of anti-personnel mines across the country, there are no reliable data on the effects of this phenomenon on outcomes for patients who were victims of these devices. Objective: The objective of this study was to assess mortality from landmine injuries before and during the Colombian peace process. Furthermore possible associations between peace negotiations and mortality were explored. Methods: For this study, we used the "Colombian Victims of Antipersonnel Mines Injuries registry" (MAP/MUSE database) data from 2002 to 2018. This registry was launched in 2001 by the government of Colombia with the aim of prospectively and systematically collect information on all the cases of anti-personnel mine injuries in the country. The period between 2002-2012 was classified as the pre-negotiation period (período de guerra), and 2014-2018 as the peace negotiations period, with 2013 classified as a washout year. Multivariate logistic regression was used to explore the association between peace negotiations and mortality among anti-personnel landmine injured individuals. Results: A total of 10306 landmine injury cases were registered. Of these, 1180 (11.4%) occurred in the peace-negotiation period. Mortality was significantly lower during the period of peace negotiations. After adjusting for sex, age group, race, active duty soldier status, rural area, and geographic Departamentos case volumes, the peace negotiation period was found to be associated with lower risk-adjusted odds of mortality after suffering a landmine injury (OR= 0.6, 95% CI, 0.5-0.7; p<0.001). Conclusions: Our findings suggest an association between the period of peace negotiation and a lower likelihood of mortality among victims of anti-personnel landmines.

Resumen Introducción: Aunque el proceso de paz colombiano produjo una reducción en la cantidad de minas antipersona en el país, no hay estimativos sobre el efecto de este fenómeno en los desenlaces de los pacientes víctimas de estos artefactos. Objetivo: Nuestro objetivo fue evaluar la mortalidad por minas antipersona antes y durante la negociación del proceso de paz en Colombia. Además, exploramos posibles asociaciones entre las negociaciones de paz y la mortalidad. Métodos: Para este estudio utilizamos los datos del "Registro de víctimas colombianas de lesiones de minas antipersona" (base de datos MAP / MUSE) de 2002 a 2018. Este registro fue lanzado en 2001 por el gobierno de Colombia con el objetivo de recolectar información de manera prospectiva y sistemática de los casos de trauma por minas antipersona en el país. Clasificamos el período comprendido entre 2002 y 2012 como el período previo a la negociación (período de guerra), el comprendido entre 2014 y 2018 como el período de negociaciones de paz y el año 2013 como período de "depuración". Se utilizaron modelos de regresión logística multivariados para explorar las asociaciones entre las negociaciones de paz y la mortalidad. Resultados: Se registraron un total de 10306 casos de lesiones por minas antipersona. De estos, 1180 (11.4%) ocurrieron en el período de negociación de paz. La mortalidad fue significativamente menor durante el período de negociaciones de paz. El análisis de regresión logística multivariado determinó que el período de negociación de paz se asoció con una menor probabilidad de mortalidad después de sufrir una lesión por minas antipersona (OR = 0,6, IC 95%, 0,5-0,7; p <0,001). Conclusiones: Nuestros hallazgos sugieren una asociación entre el período de negociación de paz y una menor probabilidad de mortalidad entre las víctimas de las minas antipersona.

COVID-19 spread, detection, and dynamics in Bogota, Colombia.

Latin America has been severely affected by the COVID-19 pandemic but estimations of rates of infections are very limited and lack the level of detail required to guide policy decisions. We implemented a COVID-19 sentinel surveillance study with 59,770 RT-PCR tests on mostly asymptomatic individuals and combine this data with administrative records on all detected cases to capture the spread and dynamics of the COVID-19 pandemic in Bogota from June 2020 to early March 2021. We describe various features of the pandemic that appear to be specific to a middle income countries. We find that, by March 2021, slightly more than half of the population in Bogota has been infected, despite only a small fraction of this population being detected. The initial buildup of immunity contributed to the containment of the pandemic in the first and second waves. We also show that the share of the population infected by March 2021 varies widely by occupation, socio-economic stratum, and location. This, in turn, has affected the dynamics of the spread with different groups being infected in the two waves.

Higher pharmaceutical public expenditure after direct price control: improved access or induced demand? The Colombian case.

BACKGROUND: High pharmaceutical expenditure is one of the main concerns for policymakers worldwide. In Colombia, a middle-income country, outpatient prescription represents over 10% of total health expenditure in the mandatory benefits package (POS), and close to 90% in the complementary government fund (No POS). In order to control expenditure, since 2011, the Ministry of Health introduced price caps on inpatient drugs reimbursements by active ingredient. By 2013, more than 400 different products, covering 80% of public pharmaceutical expenditure were controlled. This paper investigates the effects of the Colombian policy efforts to control expenditure by controlling prices. METHODS: Using SISMED data, the official database for prices and quantities sold in the domestic market, we estimate a Laspeyres price index for 90 relevant markets in the period 2011-2015, and, then, we estimate real pharmaceutical expenditure. RESULTS: Results show that, after direct price controls were enacted, price inflation decreased almost - 43%, but real pharmaceutical expenditure almost doubled due mainly to an increase in units sold. Such disproportionate increase in units sold maybe attributable to better access to drugs due to lower prices, and/or to an increase in marketing efforts by the pharmaceutical industry to maintain profits. CONCLUSIONS: We conclude that pricing interventions should be implemented along with a strong market monitoring to prevent market distortions such as inappropriate and unnecessary drug use.

Response regarding Colombian regulation of biotherapeutic products / Respuesta sobre la regulación colombiana de los productos bioterapéutico

[EXCERPT]. Regarding a letter by Erika Lietzan (1) addressing our article on regulating biotechnology drugs in Colombia (2), we offer the following response. As Lietzan states, it is true that there is a global consensus on the two regulatory pathways to obtaining market authorization for biological medicines: the full dossier pathway for pioneer products and an abbreviated pathway for competitors (biosimilars), called the “comparability pathway” in Colombia. The scientific principles of the abbreviated pathway are clearly stated in our article, referencing the WHO Guidelines on Evaluation of Similar Biotherapeutic Products (3), which underscores the importance of demonstrating a high similarity of physicochemical and functional characteristics between the biocompetitor and the reference product...

[The debate on regulating biotechnology drugs: Colombia in the international context]. / El debate de la regulación de medicamentos biotecnológicos: Colombia en el contexto internacional.

In September 2014, Colombia issued standards for the evaluation of biological drugs within the framework of the marketing authorization process. The Colombian approach explicitly includes a fast track for evaluating competing biologicals, which caused great national and international controversy. This article explains the context that justifies the need for this fast-track approach, critically analyzes comparability as a paradigm for the evaluation of biogenerics, and shows that Colombia's position is not isolated and is based on global regulatory trends.

[Proposed model for managing drugs used for unregistered indications in Colombia]. / Propuesta de un modelo de gestión de medicamentos en indicaciones no registradas en Colombia.

The use of drugs for unregistered indications, known as "off-label" use, is a practice that creates problems of rational use and access when other options are not available. Health systems should address this situation, particularly in connection with decisions concerning coverage, while trying to minimize health risks and clearly define the roles and responsibilities of the parties involved. Colombia's Ministry of Health and Social Protection (MinSalud), together with the National University of Colombia and national experts, developed a proposal for a model for managing drugs being used for unregistered indications (off-label) and their potential reimbursement with public resources, taking into account international practices and country characteristics. The management model is non-punitive and is geared toward promoting the rational use of these drugs so that barriers to access are reduced whenever their use is supported by solid scientific evidence. The model addresses patient safeguards in the bioethical domain and the roles and responsibilities of the prescriber and government entities.

El debate de la regulación de medicamentos biotecnológicos: Colombia en el contexto internacional / The debate on regulating biotechnology drugs: Colombia in the international context

En septiembre de 2014, Colombia emitió su norma para la evaluación de los medicamentos biológicos en el marco del proceso de autorización de comercialización. La aproximación colombiana incluye de manera explícita una ruta abreviada para la evaluación de los biológicos competidores que generó una gran polémica a nivel nacional e internacional. En el presente artículo se explica el contexto que justifica la necesidad de adoptar la aproximación abreviada, se analiza de manera crítica la comparabilidad como paradigma para la evaluación de los biogenéricos y se evidencia que la posición de Colombia no es aislada y está basada en tendencias regulatorias globales.

In September 2014, Colombia issued standards for the evaluation of biological drugs within the framework of the marketing authorization process. The Colombian approach explicitly includes a fast track for evaluating competing biologicals, which caused great national and international controversy. This article explains the context that justifies the need for this fast-track approach, critically analyzes comparability as a paradigm for the evaluation of biogenerics, and shows that Colombia’s position is not isolated and is based on global regulatory trends.

Propuesta de un modelo de gestión de medicamentos en indicaciones no registradas en Colombia / Proposed model for managing drugs used for unregistered indications in Colombia

El uso de medicamentos en indicaciones no registradas (INR), conocido como uso “off-label”, es una práctica que genera problemas de uso racional y de acceso cuando no existen alternativas disponibles. Los sistemas de salud deben gestionar esta realidad, sobre todo cuando se trata de decisiones de cobertura, buscando minimizar los riesgos para la salud y estableciendo de forma clara los papeles y las responsabilidades de los agentes involucrados. El Ministerio de Salud y Protección Social de Colombia (MinSalud), junto con con la Universidad Nacional de Colombia y expertos nacionales, diseñaron una propuesta de modelo de gestión del uso de medicamentos en indicaciones no registradas (off-label) y su potencial reembolso con recursos públicos, teniendo en cuenta prácticas internacionales y la realidad nacional. El modelo de gestión es no punitivo y está orientado a la promoción del uso racional de estos medicamentos, de forma que se reduzcan las barreras al acceso cuando su uso está respaldado por pruebas cientificas de calidad. El modelo incorpora elementos de garantías bioéticas del paciente, los papeles y las responsabilidades del prescriptor y de las entidades de gobierno.

The use of drugs for unregistered indications, known as “off-label” use, is a practice that creates problems of rational use and access when other options are not available. Health systems should address this situation, particularly in connection with decisions concerning coverage, while trying to minimize health risks and clearly define the roles and responsibilities of the parties involved. Colombia's Ministry of Health and Social Protection (MinSalud), together with the National University of Colombia and national experts, developed a proposal for a model for managing drugs being used for unregistered indications (off-label) and their potential reimbursement with public resources, taking into account international practices and country characteristics. The management model is non-punitive and is geared toward promoting the rational use of these drugs so that barriers to access are reduced whenever their use is supported by solid scientific evidence. The model addresses patient safeguards in the bioethical domain and the roles and responsibilities of the prescriber and government entities.

Factores asociados a letalidad de intentos de suicidio en sujetos con trastorno depresivo mayor / Factors associated with suicide attempts lethality in subjects with mayor depressive disorder

Objetivo: Identificar en una muestra de población antioqueña con trastorno depresivo mayor y antecedente de conducta suicida las características que se asocian a intentos de suicidio de alta letalidad. Método: Se evaluaron 140 sujetos con diagnóstico de trastorno depresivo mayor y antecedente de, al menos, un intento de suicidio, por medio de una entrevista diagnóstica semiestructurada. De acuerdo con las características del intento de suicidio más serio, los sujetos se dividieron en grupos de menor letalidad (letalidad leve y moderada) y mayor letalidad (letalidad alta y extrema), los cuales se compararon en variables sociodemográficas y clínicas. Resultados: Los sujetos con intentos de suicidio de letalidad alta y extrema con mayor frecuencia vivían solos, tenían antecedente de más de un intento de suicidio y presentaban dependencia a nicotina y a sustancias psicoactivas diferentes al alcohol. En el análisis multivariado se estableció que vivir solo y la dependencia a sustancias psicoactivas se asociaron de manera independiente con los intentos de suicidios de letalidad alta y extrema. Conclusiones: Los hallazgos del presente estudio se corresponden con las características clínicas descritas en estudios previos en asociación con intentos de suicidio de alta letalidad. Los presentes resultados se proponen como factores para tener en cuenta en la valoración del riesgo suicida en sujetos con trastorno depresivo mayor...

Objective: To identify the characteristics associated with high-lethality suicide attempts in a population sample IN Antioquia with major depressive disorder and suicidal behavior history. Method: A semi-structured diagnostic interview was used to assess 140 subjects diagnosed with major depressive disorder and who had made at least one suicide attempt. According to the characteristics of the most serious suicide attempt, the subjects were classified into two groups—low-lethality suicide attempters (low and moderate lethality) and high-lethality suicide attempters (high and very high lethality)—which were compared for clinical and demographic variables. Results: It was found that high- and very high-lethality suicide attempters lived alone more often, had made more than one suicide attempt, and exhibited greater dependence on nicotine and psychoactive substances, other than alcohol, than low-lethality attempters. The multivariate analysis established that living alone and being dependent on psychoactive substances were independently associated with very high- and high-lethality attempts. Conclusion: These findings confirm the clinical characteristics associated with high-lethality suicide attempts described in previous studies. The present results are proposed as factors to be taken into account for the assessment of suicidal risk in patients with major depressive disorder...

Divertículo esofágico en unpastor alemán: reporte de caso / Esophageal diverticulum in a dog: a case report

Un paciente canino de raza Pastor alemán se trató satisfactoriamente por una gastroenteritis infecciosa, sin embargo se detectó que el perro regurgitaba con frecuencia. En el esofagograma con bario se observó una gran dilatación esofágica en el tercio proximal del esófago torácico y en la esofagoscopia se confirmó la presencia de un divertículo esofágico. El tratamiento quirúrgico incluyó la toracotomía lateral con resección quirúrgica del divertículo, colocación de un tubo de drenaje torácico usando una válvula de Heimlich. También fue colocado un tubo de gastrostomía para alimentación enteral. El paciente se recuperó satisfactoriamente de la cirugía, sin presentar ninguna complicación. Los divertículos esofágicos son de presentación poco frecuente en los perros y su ruptura puede llevar a condiciones graves como mediastinitis y la muerte del paciente. La resección quirúrgica es el tratamiento de elección sólo en los divertículos que manifiesten síntomas clínicos que alteren la calidad de vida los pacientes.

A German Shepard dog was attended presenting an infectious gastroenteritis. Once the dog responded to treatment, it was noticed that the patient regurgitated frequently. In the barium esophagogram it was detected a big esophageal dilatation in the proximal third of the thoracic esophagus, and the upper endoscopy confirmed an esophageal diverticulum. The surgical intervention included a lateral thoracotomy with esophageal diverticulum resection, thoracic tube drainage with a Heimlich valve, and a gastrostomy tube placement for enteral nutrition. The patient recovered satisfactory without any complication. Esophageal diverticulum is infrequent in dogs and its rupture can lead to critical conditions as mediastinitis and death. Surgical resection is essential in the treatment of esophageal diverticulum in cases were clinical symptoms are important.

Aneurismas y seudoaneurismas de injertos venosos coronarios / Aneurysms and pseudo aneurysms from coronary venous grafts

Los aneurismas y seudoaneurismas de injertos de vena safena aortocoronarios, son una complicación inusual de la cirugía de revascularización miocárdica. En este reporte se presenta el caso de un paciente de género masculino de 61 años de edad, quien sufrió un infarto del miocardio de la pared inferior 14 años atrás. La angiografía coronaria mostró enfermedad severa de dos vasos. Se realizó anastomosis de la arteria mamaria interna izquierda, al tercio medio de la descendente anterior e injerto de vena safena al tercio distal de la arteria coronaria derecha. En marzo de 2003, consultó por dolor anginoso. La radiografía de tórax reveló una masa paracardiaca derecha. La arteriografía coronaria mostró aneurisma del puente venoso a la arteria coronaria derecha. Durante la evolución presentó hemoptisis masiva; se hizo cirugía y se halló fístula de aneurisma de puente venoso coronario al lóbulo medio del pulmón derecho. En este artículo se hace una revisión de la etiología, los hallazgos clínicos, la metodología diagnóstica y el tratamiento actual de esta entidad. Hasta la fecha de esta publicación se reportan aproximadamente 60 casos en la literatura inglesa.